Diagnosis in F.P.

D
Contents

• Introduction
• Effects of tooth loss
• Reasons for treating tooth loss
• Diagnosis
Diagnosis
• Personal habits
• Chief complaint
• Medical history
• Dental history
• Examination
General
Extra oral
Intra oral
Occlusal
Radiographic
Vitality tests
Effects of tooth loss
Drift of Neighboring Teeth :
 Effect depends upon intercuspation of
teeth on either side of space with those
of opposing arch
 Age and periodontal condition
 Tooth movements depend upon
position of tooth in arch
1) lower molars tilt mesially
2) upper molars tilt mesially and rotate
around palatal root
3) the premolars stay upright and move
bodily into any space
Over eruption of opposing
teeth
Over eruption leads to:

1.Loss of bony support for tooth

2.Overgrowth of alveolus
3.Traumatic occlusion
4.Loss of contacts which leads to food
impaction.periodontal breakdown and
subgingival caries
 Failure to maintain
space after tooth
extraction can lead to
tooth movement
unless this is
prevented
 The teeth may tilt
into the space or an
opposing tooth may
over erupt
 Either can result in
functional excursions
and periodontal
destruction
Reasons for treating tooth loss

• Esthetics
• Function
• Pain due to TMJ dysfunction
• Speech
• Maintenance of dental health
Personal Details
• The patient’s name,age,sex, address,
phone number,occupation, and marital
and financial status are noted.

• In addition to establishing rapport and

developing a basis for the patient to
trust the dentist, small and seemingly
unimportant personal details often have
considerable impact on establishing a
correct diagnosis, prognosis, and
treatment plan.
Chief Complaint

  This is the reason ,usually a symptom

or a cluster of symptoms why the
patient seeks treatment
 It can be urgent ,such as acute pain ,or
gross swelling or minor complaint.
 The chief complaint should always be
noted and addressed because it is
generally the reason why the patient
sought care in the first place
 All findings are grouped as either
symptoms (subjective ,elicited by
history and interview as described by
the patient)or signs (objective often
measurable ,discovered by
examination)
 SOAP – this acronym often seen in
medical and dental notes
 S= Subjective (symptoms elicited by
patient)
 O= Objective (signs discovered by
examination)
 A= Assessment (analysis of the
information- the diagnosis)
 P= Plan (what you intend you do about
the problem)
Chief complaints usually fall into one of
the following four categories

 Comfort (pain, sensitivity, swelling)

 Function (difficulty in mastication or
speech)
  Social (bad taste or odor)
 Appearance (fractured teeth or
restorations, discoloration)
Lack of Comfort

• If pain is present, its location,

character, severity, and frequency
should be noted, as well as the first
time it occurred, what factors
precipitate it (e.g., hot, cold, or sweet
things), and any changes in its
character .Is it localized or more
diffuse in nature ?
Impaired Function

Difficulties in mastication and speech

may result from a fractured cusp or
missing teeth.
It may also indicate a more generalized
malocclusion or dysfunction.
 Social

A bad taste or smell often indicates

compromised oral hygiene and
periodontal disease.
Often social pressures prompt the
individual to seek care.
Poor Appearance
Compromised
appearance is a
strong motivating
factor for patients
to seek advice as
to whether
improvement is
possible
 Such individuals may have missing or
crowded teeth or a tooth or restoration
may be fractured.
 Their teeth may be unattractively
shaped, malpositioned, or discolored,
or there may be a developmental
defect.
History

Medical History
• An accurate and current general
medical history should include any
medication the patient is taking as well
as all relevant medical conditions. If
necessary, the patient’s physician(s)
can be contacted for clarification.
The following classification may be
helpful: 
I)Conditions affecting the treatment
methodology
 Any disorders that necessitate the use
of antibiotic pre medication
 Any use of steroids or anticoagulants,
and any previous allergic responses to
medication or dental materials
 Once these are identified, treatment
usually can be modified as part of the
comprehensive treatment plan
II)Condition affecting the treatment
plan
 Previous radiation therapy
 Hemorrhagic disorders
 Extremes of age
 Terminal illness
For instance, the patients who have
received radiation treatment may suffer
from xerostomia,which is conducive
for greater carious activity and hence
extremely hostile for cast metal
restorations.
They are also more susceptibility for
infection following injury and delayed
healing
 Patients with prosthetic valves are on
Coumadin ,an anticoagulant.
 Thus any procedure which may induce
even minor bleeding should be
prevented.
 Patients who are immunocompromised
are more susceptible to opportunistic
disease
III)Systemic Conditions with oral
manifestations
 Periodontitis may be modified by diabetes
mellitus, menopause, pregnancy, or the use
of anticonvulsant drugs
 In case of hiatal hernia, bulimia, or anorexia
nervosa, palatal surfaces of teeth may be
eroded by regurgitated stomach acid
 Certain drugs like anticonvulsants leads to
hyperplasia of gingiva
 Patients with compromised immunity
•
II)DENTAL HISTORY
Clinicians should be cautious when
commenting before a thorough
examination is completed.
 Periodontal history
 Restorative history
 Endodontic history
 Orthodontic history
 TMJ dysfunction history
 
Periodontal History.
The patient’s oral hygiene is
assessed
Current plaque-control measures
The frequency of any previous
debridements should be recorded
the dates and nature of any
previous periodontal surgery
should be noted.
Restorative History may include
Only simple composite resin
Dental amalgam fillings,
It may involve crowns and
extensive fixed partial dentures.
The age of existing restorations
can help establish the prognosis
and probable longevity of any
future fixed prostheses.
Endodontic History.
These can be readily identified
with radiographs.
The findings should be reviewed
periodically so that periapical
health can be monitored and any
recurring lesions promptly detected
Orthodontic History.
 Occlusal analysis should be an integral
part of the assessment of a post
orthodontic dentition.
 Occlusal adjustment (reshaping of the
occlusal surfaces of the teeth) may be
needed to promote long-term positional
stability of the teeth and reduce or
eliminate parafunctional activity.
On occasion, root resorption
(detected on radio-graph)may be
attributable to previous orthodontic
treatment.
As the crown / root ratio is
affected, future prosthodontic
treatment and its prognosis may be
affected
TMJ Dysfunction History.
 A history of pain
 Clicking in the temporomandibular
joints
 Neuro-muscular symptoms such as
tenderness to palpation, may be due to
TMJ dysfunction,
 Which should be normally be treated
and resolved before fixed
prosthodontic treatment begins.
Parafunctional habits

Bruxism
• Bite Discrepancy
• Psychological Triggers
• Chemical Triggers
• Intake of “uppers” such as caffeine
and amphetamines synergistically
enhance the contractions of the jaw
muscles
• Hence the use of these drugs can
bring about rigorous clenching and
grinding
• Certain prescription drugs like the
anti-depressant, Zoloft is known to
induce Para function.
Diagnosis of Para function
• Much like diagnosis of many other
diseases, there are no “litmus tests” for
this condition In an acute case
Front to back fracture of the lower molar
2. Morning headaches in the temporal
areas.
3. May suffer from stiff neck and
shoulders.
4. May find the teeth to be sore,
especially upon awakening.
 If clenching becomes chronic
Abfraction is a condition in which the
neck of the tooth is eroded away in a
chemical reaction as it flexes under
clenching and grinding forces.
 As a result of this, the dentinal surface
becomes exposed and that area
becomes extremely sensitive.
• Sensitive areas on the neck of teeth
are usually indicative of severe clenching
 Excessive wear
facets that are flat
and shiny on the
top of the back
teeth, inconsistent
with the age of
the individual, is a
sign of grinding.
 Thinning and
chipping of the
front teeth is
another sign of
excessive wear
from grinding.
 Formation of extra
bone around the
teeth, most
commonly on the
inside surfaces of
the lower
premolars.
 Previously these
bone formations
that are called
“tori” were
thought to be of
genetic origin.
 Scalloped tongue
is a sign of
continuous
clenching
accompanied by
pressing on the
teeth by the
tongue.
EXAMINATION
 An examination consists of the clinician’s
use of sight, touch, and hearing to detect
conditions outside the normal range.
 To avoid mistakes, it is critical to record
what is actually observed rather than to
make diagnostic comments about the
condition.
 For example, “swelling,” “redness,” and
“bleeding on probing of gingival tissue”
should be recorded rather than “gingival
inflammation” (which implies a
diagnosis).
Types of Examination

 Emergency examination
 Screening examination
 Comprehensive examination
Techniques of examination

 Inspection
 Palpation
 Percussion
 Auscultation
 Olfaction
Examination
 General
 Extra oral
 Intra oral
General Examination
 The patient’s general appearance, gait,
and weight are assessed.
 Skin color is noted for signs of anemia
or jaundice.
 Vital signs, such as respiration, pulse,
temperature, and blood pressure, are
measured and recorded.
 Fixed prosthodontic treatment is often
indicated in middle-aged or older
patients, who can be at higher risk for
cardiovascular disease.
 Patients with vital signs outside normal
ranges should be referred for a
comprehensive medical evaluation
before definitive treatment is initiated.
Extra oral Examination

 Facial symmetry.

 Cervical lymph nodes are palpated

Temporomandibular Joints

Tenderness, or pain on movement, is

noted and can be indicative of
inflammatory changes in the retrodiscal
tissues, which are highly vascular and
innervated.
  TMJ can be located
Tmj ,pg 57 by palpating
bilaterally just
anterior to the
auricular tragi
while having the
patient open and
close.
 This permits a
comparison
between relative
timing of left and
right condylar
movements.
 If there is evidence of significant
asynchronous movement or TMJ
dysfunction, a systematic sequence for
comprehensive muscle palpation should be
followed as described by Solberg and Krogh-
Poulsen and Olsson.
 Each palpation site is given a numerical
score based on the patient’s response.
 If neuromuscular or TMJ treatment is
initiated, the examiner can then re palpate the
same sites periodically to assess the response
to treatment
A maximum
mandibular opening
resulting in less
than 35mm of
interincisal
movement is
considered to be
restricted, because
the average opening
is greater than
50mm.
 Similarly, any
midline deviation on
opening and or
closing is recorded.

 The maximum lateral

movements of the
patient can be
measured (normal is
about 12mm)
 Muscles of Mastication.
 Palpated for signs of tenderness.
 Palpation is best accomplished
bilaterally and simultaneously.
 This allows the patient to compare and
report any differences between the left
and right sides.
 Light pressure should be used (the
amount of pressure one can tolerate
when gently pushing on one’s closed
eyelid without feeling discomfort is a
good comparative measure),
 If any difference is reported between
the left and right sides, the patient is
asked to classify the discomfort as
mild, moderate, or severe
Lips
 The patient is observed for tooth
visibility during normal and
exaggerated smiling.
 This can be critical in fixed
prosthodontic treatment planning,
especially for margin placement of
certain metal ceramic crowns.
 Some patients show only their
maxillary teeth during smiling.
 More than 25% do not show the
gingival third of the maxillary central
incisors during an exaggerated smile
 The extent of the smile will depend on
the length and mobility of the upper lip
and the length of the alveolar process.
 When the patient laughs, the jaws open
slightly and a dark space is often
visible between the maxillary and
mandibular teeth This has been called
the negative space.
 Missing teeth, diastemas, and fractured
or poorly restored teeth will disrupt the
harmony of the negative space and
often require correction
• Lips are inspected
,palpated bimanually
and bilaterally then
reflected to reveal
labial mucosa
INTRAORAL EXAMINATION
 The intraoral examination can reveal
considerable information concerning
the condition of the soft tissues, teeth,
and supporting structures.
 The tongue, floor of the mouth,
vestibule, cheeks, and hard and soft
palates are examined, and any
abnormalities are noted.
Buccal
mucosa
including
the parotid
duct and
typical linea
alba.
The tongue
presents a
wide range of
normal in a its
size shape and
surface texture.
 The dorsum should
be examined and
palpated till the
circumvallate
papilla.retraction of
the tongue is
necessary in order to
visualize the
area,which
represents a relative
high incidence of
oral malignancy
The ventral
aspect is
appreciated for
the lingual
frenum ,typical
varicosities and
submandibular
salivary glands
 Floor of the
mouth is palpated
bimanually with
an opposing
thumb or finger
braced under the
chin,appreciating
the salivary
glands and
muscular floor of
the mouth
Residual Ridge Contour
• An ideally shaped ridge has a smooth
regular surface of attached gingiva
• Its height and width should allow
placement of a pontic that appears to
emerge from the ridge .
• Loss of residual ridge contour may lead
to unaesthetic open embrasure(BLACK
TRIANGLES),Food impaction and
percolation of saliva during speech
Siebert has classified
residual ridge
deformities into
three
• Class I defects –
labiolingually loss
of tissue with
normal ridge height
• Class II defects
– Loss of ridge
with normal
ridge width
• Class III
defects –a
combination of
loss in both
dimensions
Periodontal Examination

A periodontal examination should

provide information regarding
Oral hygiene of the patient
The response of the host tissues,
The degree of irreversible damage.
 Because long-term periodontal health
is essential to successful Fixed
Prosthodontics existing periodontal
disease must be corrected before any
definitive prosthodontic treatment is
undertaken.
Gingiva
 The gingiva should be lightly dried
before examination so that moisture
does not obscure subtle changes or
detail.
 Color, texture, size, contour,
consistency and position are noted and
recorded.
 The gingiva is then carefully palpated
to express any exudate or pus that may
be present in the sulcular area.
 
 Healthy gingiva
is pink, stippled,
and firmly bound
to the underlying
connective
tissue.
 The gingival
margin is knife-
edged, and
sharply pointed
papillae fill the
interproximal
spaces.
The width of attached gingiva can be
assessed by
• Periodontal probe
• Injecting anesthetic solution
 
 In this examination the probe is
inserted essentially parallel to the tooth
and is “walked” circumferentially
through the sulcus in firm but gentle
steps, determining the measurement
when the probe is in contact with the
apical portion of the sulcus
 Thus any sudden change in the
attachment level can be detected
• Ramifications of
a biologic width
violation if a
restorative
margin is
placed within
the zone of the
attachment.
 Probing depths (usually six per tooth ) are
recorded on a periodontal chart which also
contains other data pertinent to the
periodontal examination
 Tooth mobility or malposition
 Open or deficient contact areas
 Inconsistent marginal ridge heights
 Missing or impacted teeth
 Areas of inadequate attached keratinized
gingiva
 Gingival recession
 Furcation involvements
• Mandibular third molars frequently
(30-60%) do not have attached gingiva
around distal segment
• A Prospective abutment that does not
have attached tissue is a poor candidate
to receive a crown.
• Depth from the
attachment to the
level of the
margin is greater
than 3 mm.
• Two options were
available to
appropriately
manage
treatment: 1)
place the original
margins half the
depth of the
sulcus; 2)
perform a
gingivectomy.
• At six weeks
after the
gingivectomy
and preparation
of the teeth
• A 4-year
recall
photograph
after
placement of
the final
restorations
Dental Charting
 Dental caries
 Restorations
 Wear facets(indicative of sliding
contact sustained over time and thus
may indicate Para functional activity)
 Abrasions
 Fractures
 Malformations
 Erosions.
•
Before proceeding with the restorations
an ANALYSIS of the occlusion is done
and examined for:
 Any TMJ Pain, muscle spasm.
 Ease or Difficulty with which the
various excursions can be made
voluntarily by the patient.
 Any occlusal interference.
 Mobility of teeth during excursion of
the mandible with the teeth in contact.

 Presence, angle and smoothness of any

slide from Retruded Contact Position to
InterCuspation Position

 The type of lateral guidance.

 Presence of any contact on the non-
working side.

 Location, extent and cause of any

faceting of teeth to be restored.

 Degree of stability of the occlusion.

 Overerupted or tilted teeth interfering

with the occlusion.
• Occlusal
assessment of
restorations.
• Very thin
articulating paper is
required such GHM
which has marking
ink only one side
thus keeping it as
thin as possible.
• The marking ink is transferred from the
paper to the tooth and at any point of
contact ,provided the teeth are dry
• Special tweezers are available for
easier handling
• Helps in determining where premature
contacts exist in centric occlusion.
• It is worthwhile
while trying – in
of any
restoration, to
establish which
occlusal contacts
exist between the
patients teeth
when restoration
is out of the
mouth.
• If these contacts
are memorized
and the marks
removed they
should be
repeatable with
the restoration in
place.
General Alignment
 The teeth are evaluated for crowding,
rotation, supra-eruption, spacing,
malocclusion, and vertical and
horizontal overlap.
 Teeth adjacent to edentulous spaces
often have shifted position slightly.
 Small amounts of tooth movement can
significantly affect fixed prosthodontic
treatment.
 Tipped teeth will affect tooth
preparation design or in severe cases,
may result in a need for minor tooth
movement before restorative treatment.

 Supra-erupted teeth are often

overlooked clinically but will often
complicate fixed partial denture design
and fabrication.
RADIOGRAPHIC EXAMINATION
 Radiographs provide essential
information to supplement the clinical
examination.
Detailed knowledge of
 The extent of bone support
 The root number and morphology
 Periodontal condition of tooth
 Periapical pathology
 Retained roots
 Caries
 Restorations.
Types of radiographs

 Intraoral films- standard periapical

films,bite wing, occlusal films
 Extra oral films- Panoramic
films,,Computed
tomography,arthography,Magnetic
resonance imaging ,Lateral
cephalometric films,Bone scans.
TESTING FOR
VITALITY
Before any
restorative
treatment,
pulpal health
must be
assessed.
• Pulp testing is
often
performed
using and
electric pulp
tester
• A tooth with a
porcelain jacket
crown presents
obvious
difficulties for
electric pulp
testing due to
non
conductivity of
porcelain
 If such a tooth is suspected to be non
vital and the matter cannot be resolved
with the aid of the radiograph ,it may
be necessary to cut a small access hole
through the cingulum area to the
dentine.
 If the tooth proves vital this can be
filled with composite
 If it proves to be non vital then the
access hole serves necessary root canal
treatment.
Response to
cold stimulus
can a simple
method of
determining
vitality.
 A small pellet
of cotton wool
is soaked in
highly volatile
ethyl chloride.
Articulated Diagnostic casts

 They must be accurate reproductions of

maxillary and mandibular arches.
 Articulated diagnostic casts can
provide a great deal of information for
diagnosing problems and arriving at a
treatment plan.
 They allow an
unobstructed view
of edentulous
spaces and accurate
assessment of span
length as well as
occlusogingival
dimension
 The length of the abutment can be
accurately gauged to determine which
preparation will provide adequate
retention and resistance.
 The true inclination of abutment teeth
will also become evident,so problems
in a common path of insertion can be
anticipated.
 Further analysis of occlusion can be
conducted
 Occlusal discrepancies
 Discrepancies in occlusal plane
 Teeth that have supra erupted can be
spotted
 A thorough evaluation of wear facets,
their number size and location
DIFFERENTIAL DIAGNOSIS
 When the history and examination are
completed, a differential diagnosis is
made.
 The practitioner should determine the
most likely causes of the observed
condition(s) and record them in order
of probability.
 A definitive diagnosis can usually be
developed after such supporting
evidence has been assembled.
 A typical diagnosis will condense the
information obtained during the
clinical history taking and examination.
PROGNOSIS
 The prognosis is an estimation of the
likely course of a disease.
 It can be difficult to make, but its
importance to patient understanding
and successful treatment planning must
nevertheless be recognized.
 The prognosis of dental disorders, is
influenced by general factors(age of
the patient, lowered resistance of the
oral environment ) and local
factors(forces applied to a given tooth,
access for oral hygiene measures).
 For example, a young person with
periodontal disease will have a more
guarded prognosis than an older person
with the same disease experience.
 In the younger person, the disease has
followed a more virulent course
because of the generally less-developed
systemic resistance; these facts should
be reflected in treatment planning
 Fixed prostheses function in a hostile
environment: the moist oral
environment is subject to constant
changes in temperature and acidity and
considerable load fluctuation.
 A comprehensive clinical examination
helps identify the likely prognosis.
 All facts and observations are first
considered individually and then
correlated appropriately.
 General Factors.
 The overall caries rate of the patient’s
dentition indicates future risk to the
patient if the condition is left untreated.
 Systemic problems analyzed in the
context of the patient’s age and overall
health provide important information
 Other important factors in determining
overall prognosis are the history and
success of previous dental treatments.
 If a patient’s previous dental care has
been successful over a period of many
years, a better prognosis can be
anticipated than when apparently
properly fabricated prostheses fail or
become dislodged within a few years
of initial placement.
Local Factors.
 The observed vertical overlap of the
anterior teeth has a direct impact on the
load distributed in the dentition and
thus can have an impact on the
prognosis.
 Impactions adjacent to a molar that will
be crowned may pose a serious threat
in a younger individual in whom
additional growth can be anticipated.,
but it may be of lesser concern in an
older individual.
 Individual tooth mobility, root
angulation, root morphology, crown-
to-root ratios, and many other variables
all have an impact on the overall fixed
prosthodontic prognosis.
Conclusion

Diagnosis is a summation of the

observed problems and their
underlying etiologies.
Also, the overall outcome and
prognosis may be adversely
affected.